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In conjunction with BMJ Case Reports, DTB will feature occasional drug-related cases that are likely to be of interest to readers. These will include cases that involve recently marketed drugs for which there is limited knowledge of adverse effects and cases that highlight unusual reactions to drugs that have been marketed for several years.
Summary
The management of atopic diseases has been revolutionised by precision therapies and biological drugs that target specific immune proteins. This report elucidates a unique complication from the use of the monoclonal antibody, dupilumab, that primary care providers and subspecialists need to be aware of. A patient in her 40s consulted us for severe atopic asthma, food allergy and eczema involving the face and body. She had previously failed treatments and was started on dupilumab (which binds to the interleukin-4 [IL4] receptor and inhibits both IL-4 and IL-13). She quickly achieved remission of asthma, rhinitis and eczema. Therapy was, however, complicated by severe blepharoconjunctivitis, dry eyes and periorbital dermatitis, consistent with dupilumab-induced ocular surface disease and dupilumab-associated mucin deficiency. Following aggressive treatment of ocular disease, the patient was able to continue dupilumab injections for asthma and eczema. It is presumed that dupilumab-induced cytokine imbalance results in ocular goblet cell dysfunction, mucin deficiency and ocular disease.
Background
With advances in the understanding of molecular pathogenesis and the interest in precision medicine, novel therapies have become available for atopic eczema and asthma. Many of these therapies are based on inhibiting T cells, immunoglobulin isotypes or cytokines. Atopic eczema is a common condition that affects 20% of children and 2%–5% of adults.1 This paper describes a potentially serious ocular side effect associated with dupilumab, a monoclonal antibody used to treat atopic eczema. This drug is also approved for moderate-to-severe asthma and severe chronic rhinosinusitis with nasal polyps though the ocular …
Footnotes
Contributors MAR: organised manuscript, edited and reviewed information, contributed to patient consent form. AH: contributed to patient information and history, edited and reviewed document. SG: provided subspecialist/ophthalmology input for figure and discussion, contributed to and edited the manuscript. GK (senior author and guarantor): generated figures, reviewed mechanisms and contributed to editing and reference citation and discussion. None of the authors have any conflict of interest nor own any interests/stocks in the company making dupilumab.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
First published Reji MA, Haque A, Goyal S, et al. Dupilumab-induced ocular surface disease: a primer. BMJ Case Reports 2022;15:e249019.